Provider Demographics
NPI:1093077703
Name:ROTTA, STACEY ANNE (MD)
Entity Type:Individual
Prefix:DR
First Name:STACEY
Middle Name:ANNE
Last Name:ROTTA
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:887 CONGRESS ST
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:ME
Mailing Address - Zip Code:04102-3100
Mailing Address - Country:US
Mailing Address - Phone:207-774-6368
Mailing Address - Fax:
Practice Address - Street 1:887 CONGRESS ST
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:ME
Practice Address - Zip Code:04102-3100
Practice Address - Country:US
Practice Address - Phone:207-774-6368
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-06-10
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA1564092086S0102X
MEMD235052086S0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2086S0102XAllopathic & Osteopathic PhysiciansSurgerySurgical Critical Care